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" --San-Joaquin Counjr MPi.!?(IC`fealtf�"Sv�ces E�nv�ro `�nta �iDiv
<br /> .
<br /> GREEN FORM
<br /> DATE 1 MASTER FILE RECORD INFORMATION '4(MFR"
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<br /> $rentu.K�:�a Eos EC2srtt�2�sI f ter y /
<br /> = � � ,srs • UNIT IV
<br /> 1)Lioolt{s OWNER FILE
<br /> COMPLETE TNEFOLLOWINGPROPERTY OWNER INFORMATION: CHECKIF OWNER (iuRRENTLrONF/LEWJTHEHD
<br /> PROPERTY - - PHONE
<br /> OWNER NAME • I' -��O v `0
<br /> BUSINESS NAME SOC SEG/TAX IO#
<br /> /1)0277413rteol= Plc Ps 0-n f S 3 G- 3 9-30 V4A'
<br /> Owner Home Address DRIVER'S LICENSE M
<br /> City STATE ZIP
<br /> Owner Mmtinp AOorasa �,�"
<br /> SSS S ko K„c $i✓v. O I T1f s"
<br /> Mailing Address City �t!�IZ�13�e�1t State—r-(— Zip" �so06 Z
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<br /> CO RPO RATIO H7)< INDIVIDUAL❑ PARTNERSHIP❑ FED ArENCY❑ OTHER❑
<br /> T-,:Adp I L(Vq I FACILITY FILE A Q-C-0 2-'--3Z
<br /> .. ,.• .•..:: t:.r._ ; -
<br /> FACIIIT`10 tJ" �' ={�fiit°,[t .arCOEFgD
<br /> "y �2"•�f-"aS(f�-t'db.i � '1��� �r�'_.:`'.
<br /> �.,,,,,.. ,s,.. -*j•:ACr,OUNT.IQ 3t. �;. b1Si'rb,race- -.. H tS�w,i�:?: -. •. 'aR'�5- ,fc,'-
<br /> CoAfPLETETI'IEFOLLOWING BUSINESS I FACILITY SITE INFORMATION.'
<br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DIYIsioN? YES ❑ NO ❑
<br /> Is this an ExisTinc Business LOCATION but a NEw TYPE of regulated Business? YES `❑_ No ❑
<br /> BU51NE9SJFACILITYISITE NAMEn` ?GS A !z D. � /�#4��f� i1 /, )�
<br /> Fl`riSNO OXYGEN � ��21 K V iL {{V//rrrrrr777 --
<br /> SUITE BUSINESS PHONE
<br /> SITE ADDRESS
<br /> STATE
<br /> CITY �- ZIP Cl 1157z w �
<br /> '�p G k Tto �'� W
<br /> A t4y.: arT +Yt Sri`r { � ^pr ]tT «CC•. dNll.` �1 `` � tl)
<br /> �4C
<br /> aF UPERv soR �' � l_
<br /> Mailing Address if DIFFERENT from Factli(yAddress Attention or Care Of(opt/oval)
<br /> STATE zip."
<br /> Mailing Address City
<br /> z- rt k " � k,:.� t � .�T �'APN#'.,� ��:. '^I-».,''`.t�xW�lr�y,�.e.;. 'fC4MM�EiJT�.''4F-�1�a -nrr. y:'u'�G�,. "w��•'�S^'%ra..�,l� ps-r7�r"R,i'�k' r,S line. st :�
<br /> SIC.CoDE;+
<br /> THIRD PARTY BILLING INFO: CO/nPlete if Billing Party is different from Property Owner or Facility Operator identlfedabove.
<br /> Attention: or Care Of Iopt/onal)
<br /> BUSINESS NAME
<br /> I
<br /> PHONE
<br /> Mailing Address
<br /> STATE Zip
<br /> CITY
<br /> AGQQI/KTA,?PrfE for fees and charges
<br /> OWNER FACILtTY18USI NESS THIRD PARTY BILLING
<br /> jor,or
<br /> this tjjksitj�s,and I acknowledot that All
<br /> uII I IVIS AMII CONIPLIAsci: l.'7<VnW1.Gli(:�I k'.NT: 1.the uncle t'YiLncll +N 4,t1 illa+nituta:lctrtily that
<br /> this r the 0 rU 11011`WIT(.be lb�te'll to lute Yt,t the duress identiried above As the AC(.'0 TA I)I Nt'YS
<br /> NYKil1'rF' SAN
<br /> r•.r-S,pE,,VAt.TlFi,E.a'FVRLF-VEVr[TLiN4&Y andhir HoL'Nt.F4x G perrormcd in 2ccoroancewith all
<br /> fur this site. 1 also certify that all utfunnntiun provided ou lhisTi alntcation is dlor Fe nerue K�talLans and 11 olad;and tat all tions. s the undersigned owner`pen4tnr,or agent of the Property Inc»tntltAt the
<br /> JOAQUIN COUNTI Ordituncc Cod's al"llo"Standard!
<br /> and SIA
<br /> alcove fal:ilitylsitc address. 1 hereby authorise the release of any autf al[results and envimnnlcntul avesmenl.Infnrm+_cion to SAN.fOfi(2li]N COLiiV'T'1' EIItUNRik:hT.A.I.
<br /> 1 tE.,l rlt UIVIJIUN is-on As it u available and at the same tinicit is Provided it,Inc or my representative.
<br /> PLEASE PRINT "
<br /> �pfLTNdttoo+� P,eoplearss,2w,e., SIGNA7UR
<br /> APPLICANT NAME 3y: W,4,4,0444 1Z, �KIC t L E� SR
<br /> DRIVER'S LICENSE q N R
<br /> TITLE ?Qt.S ID6N'r
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<br /> �` letadrt3yF.
<br /> ":�AL:coutittnfl Cfbcb Procesafhg Comp
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